ITG Use Only
UC Case No.:
______________
Date received: ______________
Licensing Officer: ______________
RECORD OF INVENTION (ROI) DISCLOSURE FORM
______________________________________________________________________________________________________________________________________
Information contained in this ROI is CONFIDENTIAL and PROPRIETARY. For assistance, please call the Invention Transfer Group (ITG) at (949) 8242683. This ROI will normally not be released to others by ITG except under attorney client privilege, to research sponsors as required by contract, under
appropriate secrecy agreements, or as may be required by law. This ROI should not be disclosed to others without the approval of ITG.
_______________________________________________________________________________________________________________________________________
1. TITLE OF INVENTION
Create a short title (10 words or less) describing the invention without revealing the specific details that would enable others to make and use it.
2. UCI INVENTOR(S)
The first person listed will be the “lead,” which is ITG’s point of contact for the invention. Actual inventorship will be determined as a matter of law by a
patent attorney. Royalties resulting from the commercialization of this invention will be split equally among the inventors unless the inventors agree in
writing otherwise. The Dept. or ORU listed below will also get a share of any royalties. Add as many inventor sections as needed.
Name:
Position at UCI:
Date(s) hired/employed at UCI:
School or Division:
Dept. or ORU:
Campus Address with zip and zot code:
ITG use only. If hired pre 11/01/11, has inventor
signed new patent amendment?
Yes
No
Work Phone:
Home Address:
Mobile Phone (optional):
UCI Email:
Other email:
Name:
Position at UCI:
Date(s) hired/employed at UCI:
School or Division:
Dept. or ORU:
Campus Address with zip and zot code:
ITG use only. If hired pre 11/01/11, has inventor
signed new patent amendment?
Yes
No
Work Phone:
Home Address:
Mobile Phone (optional):
UCI Email:
Other email:
Name:
Position at UCI:
Date(s) hired/employed at UCI:
School or Division:
Dept. or ORU:
Campus Address with zip and zot code:
ITG use only. If hired pre 11/01/11, has inventor
signed new patent amendment?
Yes
No
Work Phone:
Home Address:
Mobile Phone (optional):
UCI Email:
Other email:
Page 1 of 7
3. INVENTOR(S) NOT AFFILIATED WITH UCI
If an inventor is not a UCI employee or student, please provide information below.
Name:
Position:
Nature of Employment:
Employer:
Work Phone:
Work Email:
Mobile Phone (optional):
Other email:
Name:
Position:
Nature of Employment:
Employer:
Work Phone:
Work Email:
Mobile Phone (optional):
Other email:
Work Address:
Work Address:
4. FUNDING SOURCES
Yes
Was this invention funded/sponsored?
No
If yes, list the funding source(s). If applicable, identify by contract or grant number and name the Principal Investigator / Supervisor of each.
FUNDING SOURCE / SPONSOR
CONTRACT OR GRANT NUMBER
PRINCIPAL INVESTIGATOR / SUPERVISOR
5. AGREEMENTS
Please list any agreement(s) that might affect ANY rights or interest in the invention. Check all applicable agreements and list name of other party.
Please attach copies of the agreements, if available.
TYPE OF AGREEMENT
Consulting Agreement
Assignment Agreement
Material Transfer Agreement
Other Agreement
NAME OF OTHER PARTY
Yes
No
Yes
No
Yes
No
Yes
No
6. SOFTWARE COMPONENT
Is there an integral software component to this invention?
Yes, software is an integral component to this invention.
If so, please complete the rest of this form and attach a completed copy of
“UCI Software/Copyright Disclosure Form” found on ITG’s website.
UCI Software/Copyright Disclosure Form is attached:
Software is not an integral component of this invention.
Page 2 of 7
Yes
No
7. PROPRIETARY MATERIALS
If any proprietary material (e.g., cell line, antibody, plasmid, computer software, or chemical compound) obtained from outside your laboratory was
used to develop this invention, please check the box below and attach a copy of that agreement.
TYPE OF PROPRIETARY MATERIAL
DESCRIPTION
Proprietary database (e.g., Celera)
Proprietary assay, microarray, etc.
Affymetrix chips
A material obtained via a Material Transfer
Agreement
Other
Y
N
Y
N
Y
N
Y
N
Y
N
PROVIDER NAME
8. RELEVANT DATES
EVENT
DATE
WHERE RECORDED & TO WHOM DISCLOSED
Initial Conception
First description of complete invention
(oral or written)
First Successful Operation (first actual
reduction to practice)
9. PUBLIC DISCLOSURES
Has the invention been
submitted,
accepted, or
already published/presented
to a
journal,
conference,
meeting,
thesis committee
and/or library?
If so, what is the earliest date the information will be or
was publicly available?
Name of journal, conference, or meeting:
Other than the above, was the invention made public or disclosed to non-UCI personnel (including research sponsor)?
Yes
No
If so, to whom?
When was the earliest date disclosed?
Please append copies of any publications and disclosure(s) to this form.
10. DESCRIPTION OF THE INVENTION
If you have written a manuscript that describes your invention, please attach a copy to this form. Also attach copies of the most pertinent references as
well.
A) FIELD OF THE INVENTION
Unless readily apparent from the title, please (1) list a broad field of the technology (ie chemistry, pharmacology, medical device, automotive,
agricultural, software gaming, etc.) and (2) state a very concise field or goal (ie “Pharmacology: A drug for treating and preventing the onset of
Alzheimer’s disease”).
Page 3 of 7
Has a patent search been performed (www.google.com/patents, www.uspto.gov, etc.)?
Yes
No
If yes, by whom? _____________________________
Has a literature search been performed?
Yes
No
If yes, by whom? _____________________________
B) BACKGROUND OF THE INVENTION/DISCUSSION OF PRIOR ART
Here, discuss the context of the invention: (1) the problem; (2) current solutions (”prior art”) if any; and (3) the disadvantages, limitations and
shortcomings of the prior art. This section B is for background/prior art only. Your invention itself will be discussed in sections C-F.
C) SUMMARY OF THE INVENTION
In layman terms, please give a brief overview of the invention itself. Include how it is to be used and/or why it is useful.
D) DETAILED DESCRIPTION OF THE INVENTION
Please describe in as much detail as possible the invention itself. Start with what is the unique and novel feature. Include details on how to actually
make, assemble, synthesize, or build the invention and details on how it is used once it is made. Include data, drawings, figures, supporting literature,
your thoughts and logic behind it. If the invention involves chemistry or biology, provide proof that the process or compound exists and functions in the
way you claim.
Page 4 of 7
E) COMPARATIVE BENEFITS/ADVANTAGES
Point out how your invention overcomes the disadvantages, limitations and shortcomings of the prior art described in section B. Use comparative
terms such as “less expensive”, “more efficient”, “faster”, “less energy consuming”, “safer”, “less side effects” etc.
F) STAGE OF DEVELOPMENT OF THE INVENTION
Unless stated above, describe the stage of development of the invention (e.g., concept stage, experimental stage, computer model simulation stage,
working prototype stage, etc.). Please include data, photographs, etc., indicating the stage of development.
G) FUTURE STEPS/PLANS FOR THE INVENTION
What are your immediate and future developmental or commercial steps/plans for the invention, and what is the approximate time frame for each?
H) POTENTIAL LICENSEES OR RESEARCH & DEVELOPMENT SPONSORS
List the companies or industries that you believe might be interested in making, using, or selling this invention. Please list any contact information that
we may use to market your invention.
Page 5 of 7
I)
KEYWORDS
List any keywords that will identify this invention for use on a search engine or database
J) REASON FOR SUBMITTING INVENTION DISCLOSURE
Please check the reason(s) that best describe why you submitted this invention disclosure.
I/we believe that the invention has significant commercial potential.
I/we believe that this invention is a platform and/or pioneering technology.
I/we are aware of a specific company that is interested in licensing the technology.
I/we are interested in being involved with a start-up company based on this technology.
To comply with requirements of an existing research agreement or University policy.
Other (please specify):
K) INVENTORS’ SIGNATURES
___________________________
Inventor signature
___________________________
Inventor Printed Name
______________
Date signed
___________________________
Inventor signature
___________________________
Inventor Printed Name
______________
Date signed
___________________________
Inventor signature
___________________________
Inventor Printed Name
______________
Date signed
___________________________
Witness signature
___________________________
Witness Printed Name
______________
Date signed
___________________________
Witness signature
___________________________
Witness Printed Name
______________
Date signed
L) WITNESSES
Two technically qualified witnesses are required.
Invention disclosed and understood by:
Submit the ORIGINAL with SIGNATURES directly to:
Kevin Kennan
Associate Director
Invention Transfer Group
5141 California, Suite 200
Irvine, CA. 92617
Zot 7700
Also, email (1) the MS Word copy and (2) a scan of the document with signatures to Kevin Kennan (kkennan@rgs.uci.edu) and
Flor Blickhahn (flor.blickhahn@rgs.uci.edu). If you do not receive an acknowledgment within 30 days, please contact Flor at
(949) 824-3133.
Page 6 of 7
NOTE:
DISTRIBUTION OF A COMPLETED FORM TO THIRD PARTIES IS PROHIBITED, AS CONFIDENTIAL,
PROPRIETARY UNIVERSITY INFORMATION IS CONTAINED IN ANY COMPLETED FORM.
©1987, 2011, 2012, 2016 The Regents of the University of California
All Rights Reserved
Page 7 of 7